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The childhood obesity epidemic in America is a national health crisis. One in every three children (31.7%) ages 2-19 is overweight or obese.1 The life-threatening consequences of this epidemic create a compelling and critical call for action that cannot be ignored. Obesity is estimated to cause 112,000 deaths per year in the United States,2 and one third of all children born in the year 2000 are expected to develop diabetes during their lifetime.3 The current generation may even be on track to have a shorter lifespan than their parents.4 Along with the effects on our childrens health, childhood obesity imposes substantial economic costs. Each year, obese adults incur an estimated $1,429 more in medical expenses than their normal-weight peers.5 Overall, medical spending on adults that was attributed to obesity topped approximately $40 billion in 1998, and by 2008, increased to an estimated $147 billion.6 Excess weight is also costly during childhood, estimated at $3 billion per year in direct medical costs.7 Childhood obesity also creates potential implications for military readiness. More than one quarter of all Americans ages 17-24 are unqualified for military service because they are too heavy.8 As one military leader noted recently, We have an obesity crisis in the country. Theres no question about it. These are the same young people we depend on to serve in times of need and ultimately protect this nation. 9 While these statistics are striking, there is much reason to be hopeful. There is considerable knowledge about the risk factors associated with childhood obesity. Research and scientific information on the causes and consequences of childhood obesity form the platform on which to build our national policies and partner with the private sector to end the childhood obesity epidemic. Effective policies and tools to guide healthy eating and active living are within our grasp. This report will focus and expand on what we can do together to: 1. create a healthy start on life for our children, from pregnancy through early childhood; 2. empower parents and caregivers to make healthy choices for their families; 3. serve healthier food in schools; 4. ensure access to healthy, affordable food; and 5. increase opportunities for physical activity.
What is Obesity?
Obesity is defined as excess body fat. Because body fat is difficult to measure directly, obesity is often measured by body mass index (BMI), a common scientific way to screen for whether a person is underweight, normal weight, overweight, or obese. BMI adjusts weight for height,10 and while it is not a perfect indicator of obesity,11 it is a valuable tool for public health. Adults with a BMI between 25.0 and 29.9 are considered overweight, those with a BMI of 30 or more are considered obese, and those with a BMI of 40 or more are considered extremely obese.12 For children and adolescents, these BMI categories are further divided by sex and age because of the changes that occur
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during growth and development. Growth charts from the Centers for Disease Control and Prevention (CDC) are used to calculate childrens BMI. Children and adolescents with a BMI between the 85th and 94th percentiles are generally considered overweight, and those with a BMI at or above the sex-and age-specific 95th percentile of population on this growth chart are typically considered obese. Determining what is a healthy weight for children is challenging, even with precise measures. BMI is often used as a screening tool, since a BMI in the overweight or obese range often, but not always, indicates that a child is at increased risk for health problems. A clinical assessment and other indicators must also be considered when evaluating a childs overall health and development.13
18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008
Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Surveys. Note: Obesity is de ned as BMI gender- and weight-speci c 95th percentile from the 2000 CDC Growth Charts
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Race/Ethnic Disparities
Childhood obesity is more common among certain racial and ethnic groups than others. Obesity rates are highest among non-Hispanic black girls and Hispanic boys. Obesity is particularly common among American Indian/Native Alaskan children. A study of four year-olds found that obesity was more than two times more common among American Indian/Native Alaskan children (31%) than among white (16%) or Asian (13%) children. This rate was higher than any other racial or ethnic group studied.17
GIRLS
GIRLS
Non-Hispanic White
Non-Hispanic Black
Hispanics
Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey; Note: Obesity is de ned as BMI gender- and weight-speci c 95th percentile from the 2000 CDC Growth Charts
Socioeconomic Disparities
Among adults, obesity rates are sometimes associated with lower incomes, particularly among women. Women with higher incomes tend to have lower BMI, and the opposite is true, those with higher BMI have lower incomes.18 A study in the early 2000s found that about 38% of non-Hispanic white women who qualified for the Supplemental Nutrition Assistance Program (known then as food stamps), were obese, and about 26% of those above 350% of the poverty line were obese.19 Also, a recent study of American adults found lower rates of obesity among individuals with more education. Specifically, the study found that nearly 35% of adults with less than a high school degree were obese, compared to 21% of those with a bachelors degree or higher.20 The relationship between income and obesity in children is less consistent than among adult women,21and sometimes even points in the opposite direction. Another study from the early 2000s found that only among white girls were higher incomes associated with lower BMI. Among AfricanAmerican girls, the prevalence of obesity actually increased with higher socioeconomic status, suggesting that efforts to reduce ethnic disparities in obesity must target factors other than income and education, such as environmental, social, and cultural factors.22
GIRLS
BOYS
BOYS
BOYS
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Regional Disparities
Across the country, the prevalence of obesity has been found to be highest in southeast states such as Alabama, Mississippi, South Carolina, Tennessee, and West Virginia, as well as in Oklahoma. It is lowest in Colorado.23 Another study showed obesity was most common among adults in the Midwest and the South, as well as among adults who did not live in metropolitan areas.24
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Studies show that early influences can affect obesity rates. The increased occurrence of obesity among children of obese parents suggests a genetic component.44 Multiple twin and adoption studies also indicate a strong genetic component to obesity.45 However, genes associated with obesity were present in the population prior to the current epidemic; genes only account for susceptibility to obesity and generally contribute to obesity only when other influences are at work. Genetic susceptibility to obesity is significantly shaped by the environment.46 In addition to genetic factors, recent research has focused on other factors, such as maternal nutrition, environmental toxins, and the prenatal environment, which may shape later risk for childhood obesity.
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behavioral risk factors associated with obesity.56 These risk factors fall into three general categories: (1) material incentives, such as the cost of food or the desire to avoid poor health; (2) social norms, such as the nutritional and physical activity habits of friends and family, which influence us greatly; and (3) the broader environment, such as whether grocery stores and playgrounds are nearby or far away. Changes in each of these risk factors are possible. For example, with sound information, parents and caregivers will be able to seek out the most nutritious foods to improve their childrens health; changes in social norms can be brought about through movements such as the successful seatbelt buckling campaigns of the late 20th century; and changes can be made in the broader environment by eliminating food deserts or playground deserts. In many parts of the country, we already have a head start, and initiatives that are already underway will provide instructive lessons. Comprehensive, community-wide efforts to reduce obesity have recently been initiated by both the public and private sectors. The American Recovery and Reinvestment Act of 2009 included $1 billion in funding for prevention and wellness investments, more than half of which was directed to prevention strategies to reduce tobacco use and obesity rates. Specifically, $373 million supported direct community-based interventions and $120 million supported state-based efforts in all 50 states and 25 communities in urban, rural, and tribal areas. Funds to support comprehensive strategies were awarded to states in February and to communities in March. The recently-enacted Patient Protection and Affordable Care Act, as amended by the Health Care and Education Affordability Reconciliation Act (collectively referred to as the Affordable Care Act) provides for additional investments in chronic disease and improving public health, which could include community-based prevention strategies. In addition, the philanthropic sector has been leading the way with stepped-up, focused investments. For example, the Robert Wood Johnson Foundation has created a Healthy Kids, Healthy Communities initiative that is funding 50 communities to implement strategies to prevent childhood obesity,57 and the California Endowment recently launched a large-scale Building Healthy Communities project in 14 communities that will include a focus on childhood obesity prevention.58 Reducing childhood obesity does not have to be a costly endeavor, however. And indeed, in many communities it simply cannot be. Times are tough, and federal, state, local, and family budgets are all feeling squeezed. But a great deal can be accomplished without significant expenditures, and some steps may ultimately save money.59 While many of the recommendations in this report will require additional public resources, creative strategies can also be used to redirect resources or make more effective use of existing investments. In total, this report presents a series of 70 specific recommendations, many of which can be implemented right away. Summarizing them broadly, they include: Getting children a healthy start on life, with good prenatal care for their parents; support for breastfeeding; adherence to limits on screen time; and quality child care settings with nutritious food and ample opportunity for young children to be physically active. Empowering parents and caregivers with simpler, more actionable messages about nutritional choices based on the latest Dietary Guidelines for Americans; improved labels on food and menus that provide clear information to help make healthy choices for children; reduced marketing of unhealthy products to children; and improved health care services, including BMI measurement for all children.
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Providing healthy food in schools, through improvements in federally-supported school lunches and breakfasts; upgrading the nutritional quality of other foods sold in schools; and improving nutrition education and the overall school environment. Improving access to healthy, affordable food, by eliminating food deserts in urban and rural America; lowering the relative prices of healthier foods; developing or reformulating food products to be healthier; and reducing the incidence of hunger, which has been linked to obesity. Getting children more physically active, through quality physical education, recess, and other opportunities in and after school; addressing aspects of the built environment that make it difficult for children to walk or bike safely in their communities; and improving access to safe parks, playgrounds, and indoor and outdoor recreational facilities. Many of these recommendations are for activities to be undertaken by federal agencies. All such activities are subject to budgetary constraints, including the weighing of priorities and available resources by the Administration in formulating its annual budget and by Congress in legislating appropriations.
2030: 5.0%
0% 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008 2012 2016 2020 2024 2028
Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Surveys. Note: Obesity is de ned as BMI gender- and weight-speci c 95th percentile from the 2000 CDC Growth Charts.
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In addition to monitoring the overall trends in childhood obesity, two key indicators will show the progress achieved: 1. The number of children eating a healthy diet, measured by those who follow the most recent, science-based Dietary Guidelines for Americans (Dietary Guidelines). We can monitor our progress through the U.S. Department of Agricultures (USDA) Healthy Eating Index (HEI), which reflects the intake of 12 dietary components: total fruit (including juice); whole fruit (not juice); total vegetables; dark green and orange vegetables and legumes; total grains; whole grains; milk products; meat and beans; oils; saturated fat; sodium; and calories from solid fats and added sugars. USDA generally regards a score of at least 80 out of 100 points as reflecting a healthy diet. Currently, the average child scores a 55.9 on the HEI.60 To achieve a score of 80 for the average child by 2030, the average child should score 65 by 2015, and 70 by 2020. Two indicators should be monitored particularly closely: Less added sugar in childrens diets. Children today consume a substantial amount of added sugars through a whole range of products. Using existing data sources, CDCs National Center for Health Statistics can determine how much added sugar children are currently consuming. Targets for reducing added sugar will then need to be established that track the overall goal of driving obesity rates down to 5% by 2030. More fruits and vegetables. Currently, children and adolescents consume far lower quantities of fruits and vegetables than recommended in the Dietary Guidelines.On average, children consumed only 64% of the recommended level of fruit and 46% of the recommended level of vegetables in 2003-04. Average fruit consumption should increase to 75% of the recommended level by 2015, 85% by 2020, and 100% by 2030; vegetable consumption should increase to 60% of recommended levels by 2015, 75% by 2020, and 100% by 2030. 2. The number ofchildren meeting current physical activity guidelines. Right now, the only regular survey that shows whether children are meeting the Physical Activity Guidelines is limited to high school students, and regular data on younger children is not available. Resources will have to be redirected to develop a survey instrument that can provide a full picture of physical activity levels among children of all ages. Once baseline data is available, targets for improving the level of physical activity among children will need to be established that track the overall goal of driving obesity rates down to 5% by 2030. Additional benchmarks of success, tied to specific recommendations in this report, are included throughout. The Healthy People goals set every decade by experts convened by the U.S. Department of Health and Human Services will provide additional, complementary opportunities to measure our progress in helping children achieve and maintain a healthy weight. Monitoring our progress and the impact of our interventions, so that we know what is working and what strategies or tactics need to be adjusted, will be critically important. This is not an easy challenge, but it is one that we can solve as a society, and within a generation.
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